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Formulario Médico PDF
Formulario Médico PDF
Male
Name Sex Female Birthday ()
Present mailing address Photo
(Stamped Official
Stamp)
Nationality Birth Blood type
(or Area) place
Have you ever had any of the following diseases?
(Each item must be answered Yes or No)
()
Do you have any of the following diseases or disorders endangering the public order and security?
(Each item must be answered Yes or No)
ToxicomaniaNo Yes
Mental confusionNo Yes
Psychosis Manic paychosisNo Yes
Paranoid psychosisNo Yes
HallucinatoryNo Yes
Height CM Weight Kg Blood pressure mmHg
Development Nourishment Neck
L L
Vision R Corrected vision R Eyes
Colour sense Skin Lymph nodes
Ears Nose Tonsils
Heart Lungs Abdomen
Extremities Nervous system
Spine
Other abnormal findings
X ECC
()
Chest X-ray exam
(attached chest X-ray
report)
(
)
Laboratory exam
(attached test report of
AIDS, Syphilis etc)
:
None of the following diseases of disorders found during the present examination.
Cholera Venereal Disease
Yellow fever Lung tuberculosis
Plague AIDS
Leprosy Psychosis
Suggestion Official Stamp
Signature of physician Date